Every finding on record at Oakview Skilled Nursing

Based on record review and interview, the facility failed to ensure the care plan on self-administration of medications was updated accordingly based on staff evaluation and resident preferences for 1 of 12 sampled residents (Resident 47). This failure had the potential to negatively affect Resident 47's responsiveness to care and treatment. During a review of Resident 47's admission Record (AR), dated 7/16/26, the AR indicated in part that Resident 47 is a [AGE] year-old female who was initially admitted to the facility on [DATE], with admitting diagnoses including chronic diastolic congestive heart failure (a condition where the heart becomes stiff and can not relax properly between beats), gastroesophageal reflux disease (GERD - a chronic digestive condition where stomach acid repeatedly flows back into the esophagus), and dependence on supplemental oxygen.During a review of Resident 47's Care Plan Reports, the reports indicated a care plan was initiated on 4/21/23 and subsequently revised on 3/7/25, which focused on Resident 22's Right/need/desire to exercise self-determination as evidenced by administering her eye drops, Cepacol lozenges (instant acting sore throat relief), and Tums (a common antacid used to rapidly relieve heart burn, acid indigestion, and sour stomach) tablets on her own and keeping them in her nightstand. She also likes to hold on to her medication by bedside to take at her own time. The care plan has not been updated since 3/7/25.During a review of Resident 47's Medication Administration Record (MAR), for July 2026, the MAR indicated the medication orders, Tums. 500 mg (milligram), give one (1) tablet by mouth as needed for. unsupervised self-administration (coded as U-SA) two times a day (order date: 3/15/24) and Cepacol mouth/throat lozenge 15-2.3 mg. give one (1) lozenge by mouth every two hours as needed. unsupervised self-administration, allow lozenge to dissolve slowly in mouth (order date: 4/11/23). Staff continues to document the administration of these medications as U-SA,During a review of Resident 47's Self-Administration of Medications evaluations dated 1/20/26 and 4/21/6 respectively, staff evaluations of Resident 47's ability to self-administer her medications were reviewed. As of 1/20/26, Resident 47's evaluation indicated: Resident has the ability to self-administer meds/treatments. Resident is trainable to self-administer with supervision, and Resident is self-trainable to self-administer independently. As of the most recent evaluation dated 4/21/26, Resident 47 responded NO to the question, Does the resident express an interest in self-administration of medication?During a concurrent interview and record review on 7/15/26 at 3:33 p.m. with the Director of Nursing (DON), Resident 47's clinical record was reviewed. DON verified that Resident 47's most recent self-administration of medication evaluation, dated 4/21/26, clearly documented that Resident 47 declined the opportunity to self-administer her medications. Additionally, DON confirmed and acknowledged that Resident 47's care plan and medication orders pertaining to unsupervised self-administration of medications should have been revised to accurately reflect the resident's current evaluation and expressed preferences.During a review of the facility's policy and procedures (P&P) titled Nursing Services - Care Plan, revised 10/24/25, the P&P indicated in part, The facility shall implement each patient's care plan according to patient's needs, physician orders, resident preferences and facility protocols as indicated.

Based on interview and record reviews, the facility failed to ensure written bed-hold notice was provided to the resident representative at the time of transfer to the hospital for 1 of 12 sampled residents (Resident 51). This failure had the potential to prevent the resident representative from understanding the duration of the bed hold policy and the resident's rights to return to the facility. During a review of Resident 51's admission Record (AR), dated 7/16/26, the AR indicated, Resident 51 was admitted in the facility on 5/2/26. During a review of Resident 51's Progress Note (PN), dated 5/26/26, the note indicated, Resident 51 was transferred to hospital for further evaluations. During a review of Resident 51's admission Note (AN), dated 5/27/26, the note indicated staff spoke with Resident 51's wife regarding holding the resident's bed. The wife declined to hold the bed. The record did not contain evidence that written bed hold notice was provided directly to Resident 51 or the resident representative at the time of transfer.During an interview on 7/16/2026 at 10:48 AM with admission Director, AD stated she did not provide written bed-hold notices to residents or their representatives and only contacted families verbally to remind them of the facility's bed-hold policy. During an interview on 7/16/2026 at 11:09 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated the written notice was included in the transfer documents that accompanied Resident 51 to the hospital. LVN 1 acknowledged the notice was not provided directly to the resident representative.During a concurrent interview and record review on 7/16/26 at 11:30 AM, with the Director of Nursing (DON), the facility's bed hold notice policy was reviewed. The policy directed staff to include the written notice with the resident's transfer documents but did not require the notice to be provided to both the resident and resident representative at the time of transfer. DON acknowledged this practice and stated staff did not routinely provide written notice because they did not know whether the resident would return the same day and some resident representative did not want to pay privately to hold the bed.

Based on record review and interview, the facility failed to ensure specific diagnoses were included in the MDS (Minimum Data Set - a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment for 1 of 12 sampled residents (Resident 22). This oversight resulted in an inaccurate representation of Resident 22's health condition and could potentially introduce risks to the resident's health and safety. During a review of Resident 22's hospital records, prior to admission to this facility, the Emergency Provider Report (emergency room physician documentation that details a patient's urgent medical visit. assessment findings. diagnoses and treatment plan), dated 5/16/26, indicated in part Resident 22's Past Medical History including a diagnosis of Chronic Iatrogenic Constipation (infrequent, hard stools caused by medications or medical treatments). The report also listed Resident 22's Home Medications including Methylnaltrexone Bromide (a medication used to treat chronic constipation caused by narcotic pain medications). and Prucalopride Succinate (a medication used to treat Chronic Idiopathic [of unknown cause] Constipation). During a review of Resident 22's admission Record (AR), dated 7/16/26, the AR indicated in part that Resident 22 is a [AGE] year-old male who was admitted to the facility on [DATE] with admitting diagnoses including gastroesophageal reflux disease (GERD - a chronic digestive condition where stomach acid repeatedly flows back into the esophagus), diverticulitis (a condition when the lining of the large intestine becomes inflamed or infected), and UNSPECIFIED constipation.During a review of Resident 22's Order Summary Report (OSR - list of physician orders), dated 7/16/26, the OSR indicated the medication orders: Methylnaltrexone Bromide. give 450 mg (milligram) by mouth one time a day for blocking opioid (narcotic) effects to reduce constipation and Prucalopride Succinate oral tablet 2 mg. give one (1) tablet by mouth in the morning for chronic idiopathic constipation. give before breakfast.During a review of Resident 22's MDS Assessment. Section I - Active Diagnoses, with an assessment reference date of 5/30/26, the assessment failed to indicate the diagnoses of chronic iatrogenic constipation and chronic idiopathic constipation despite the resident having ongoing treatment for these conditions.A review of the Centers for Medicare and Medicaid Services (CMS - a federal agency within the United States Department of Health and Human Services [DHHS] that actively inspects and reports on every nursing home in the United States) Resident Assessment Instrument (RAI) Version 3.0 Manual, under Section I: Active Diagnoses (Other), Coding Tips indicated, The following indicators may assist assessors in determining whether a diagnosis should be coded as active in the MDS . In the absence of specific documentation that a disease is active, the following indicators may be used to confirm active disease . ongoing therapy with medications or other interventions to manage a condition that requires monitoring . A medication indicates active disease if that medication is prescribed to manage an ongoing condition that requires monitoring or is prescribed to decrease active symptoms associated with a condition .During a concurrent interview and record review on 7/16/26 at 11:37 a.m., with the Director of Nursing (DON) and MDS Coordinator (MDSC), Resident 22's clinical records were reviewed. DON and MDSC confirmed that a diagnosis of UNSPECIFIED CONSTIPATION was listed in Resident 22's AR, dated 7/16/26. However, a further review of the resident's clinical records, including past hospital records, revealed that the resident is currently prescribed medications indicated for two specific constipation types: chronic iatrogenic and chronic idiopathic. DON and MDSC also acknowledged that these two types were not documented in Resident 22's MDS Assessment, dated 5/30/26. After consulting the CMS RAI Version 3.0 Manual's Section I: Active Diagnoses, DON and MDSC agreed that these specific constipation types should have been included in the resident's list of active diagnoses list to accurately reflect Resident's 22's current health status.

Based on interview and record review the facility failed to develop a comprehensive care plan addressing anticoagulant medication use and the associated risk for bleeding for one of 12 sampled residents (Resident 17).This failure had the potential for staff to be unaware of the interventions necessary to monitor for and reduce the risk of bleeding complications. During a review of the facility's policy and procedure (P&P) titled, Nursing Services - Care Plan, dated 10/24/25, the P&P indicated, The facility shall implement each patient's care plan according to patient needs, physician orders, resident preferences, and facility protocols as indicated. During a review of Resident 17's admission Record (AR), dated 7/15/26, the AR indicated, Resident 17 was admitted to the facility on [DATE] with diagnoses that includes fracture of left femur (a broken left thighbone) and atrial fibrillation (an irregular and often very fast heartbeat). During a review of Resident 17's, Physician Order (PO), dated 6/25/26, the PO indicated Apixaban (blood thinner) Oral tablet 2.5 mg (Milligram). Give 1 tablet by mouth two times a day for deep vein thrombosis prophylaxis (preventing blood clots in the deep veins, usually in the legs). During a concurrent interview andResident 17's comprehensive care plan on 7/15/26 at 1:17 PM., with the Director of Nursing, showed Resident 17's comprehensive care plan did not address the resident's anticoagulant medication use or the associated risk for bleeding related to apixaban therapy and DON confirmed the care plan.

Based on observations, interviews, and record review, the facility failed to ensure infection control practices were implemented when: 1. Rehabilitation staff entered a Contact Isolation (infection control measures used to prevent spread of infections through direct (touching resident) or indirect (residents environment)) room without personal protective equipment (PPE - protective clothing such as gowns, gloves, face shields or other equipment) for one of three sampled Residents (Resident 2). 2. Proper identifier for enhanced barrier precautions (EBP - an infection control intervention used to reduce transmission of MDROs (multidrug-resistant organisms that includes use of PPE during high-contact resident care) was not placed on Residents door alerting staff to use PPE, for one of three sampled residents (Resident 3). These deficient practices had the potential to cause cross contamination and the spreading of MDRO's among residents. 1. During a review of the facility's policy and procedure P&P titled, Enhanced Standard Precautions (ESP), undated, the P&P indicated, Policy Statement: . to reduce and/or prevent the transmission of pathogens, including Multi-Drug-Resistant Organisms (MDRO) and viruses. D. Contact Precautions: . gowns and gloves are required for all resident contact. Contact Precautions must be implemented for a resident known or suspected to be infected or colonized with micro-organisms contained within such things as excessive uncontained wound drainage, fecal incontinence or other body fluids that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Signs used to Alert staff of Contact Precautions: d) Signs: Color coded signs will be used to alert staff of the implementation of isolation precautions, while protecting the privacy of the resident. Orange is the color code for Contact Precautions. During an observation on 07/30/25 at 12:20 p.m., in the hallway outside room [ROOM NUMBER], observed PPE (personal protective equipment - protective clothing such as gowns, gloves, face shields or other equipment) and an orange contact isolation precautions sign on the door that occupied two residents. Observed a staff member at the bedside of Resident 2 not wearing PPE, gown or gloves. Witnessed this staff member leave the Residents room without using hand sanitizer or washing hands, enter the nurses station and proceed back to room [ROOM NUMBER] and enter with PPE or hand sanitizer. During an interview on 07/30/25 at 12:20 p.m. with Director of Rehab (DOR), DOR stated she did not know Resident 2 was on isolation precautions and assumed the isolation was for another resident in the room. The DOR stated Resident 2 was newly admitted to the facility and does not know Resident 2's isolation stating, did not check prior to seeing Resident 2. DOR acknowledged she saw the contact isolation sign on the door but states didn't know if PPE is to be worn when entering the room. During an interview on 07/30/25 at 12:25 p.m., with Licensed Nurse (LN) 1, LN1 stated Resident 2 was on contact isolation precautions for an active MDRO infection being treated with antibiotics and confirmed the DOR should should have worn PPE, including gown and gloves when entering the room. During an interview on 07/30/25 at 1:10 p.m. with Nursing Supervisor (NS), NS confirmed that Resident 2 was on contact isolation precautions for MDRO stated that staff should be wearing gowns when entering the room. The NS agreed that DOR should have worn PPE, including gown and gloves. 2 . During a review of the facility's policy and procedure (P&P) titled, Enhanced Standard Precautions (ESP), undated, the P&P indicated, . Signs: Color-coded signs will be used to alert staff of the implementation of isolation precautions, while protecting the privacy of the resident. During an interview on 07/30/25 at 12:25 p.m. with LN1, LN1 stated that residents on EBP, require staff to wear PPE during patient care and that an EBP sign should be posted outside the resident's room. During an observation on 07/30/25 at 12:45 p.m., in room [ROOM NUMBER], Resident 3 was observed in bed, with a Foley bag on the lower side of the bed. Resident 3 room did not have isolation (EBP) sign posted on the door to alert staff.During an interview on 07/30/25 at 1:10 p.m. with NS, the NS confirmed that a Resident has an indwelling device such as a Foley catheter (tube placed and left in the bladder to drain urine into a bag), they would be placed on EBP (enhanced barrier precautions - an infection control intervention used to reduce transmission of MDROs that includes use of PPE during high-contact resident care) and a sign would be placed on Residents door alerting staff to use PPE. The NS acknowledges there was no EBP sign on Resident 3's door, and stated the signage should have been posted upon admission.

Based on interview and record review, the facility failed to ensure policies and procedures (P&P) were implemented for two of three sampled Residents (Resident 1 and Resident 3) when nursing staff failed to verify residents' wishes regarding Cardiopulmonary Resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating) upon admission. This failure had the potential to result in the facility staff providing or delaying medical treatment and services against the will of the residents.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 05/2024, the P&P indicated, Policy: . [facility name] shall promote the exercise of rights for all residents, including those who face, barriers, such as communication problems, hearing problems, and cognition limits, in the exercise of these rights .13. Right to formulate an advanced directive. F. a) If the physician agrees to admit the resident, the physician will be referred to the appropriate nursing station to provide orders unless he/she has already provided said orders. G. The HID or designee will supply the nursing station with the POLST [ Physician Orders for Life-Sustaining Treatment - a document that outlines a seriously ill or frail person's preferences for medical care, particularly at the end of life] form along with other consent forms needed for resident's admission. H. The licensed nurse will introduce and complete the POLST form (if needed) during the admission assessment of the resident, if possible. I. The licensed nurse will convey to the physician of record the wishes of the resident as indicated on the POLST form by faxing the form to the physician as soon as possible in order to obtain the physician's order reflecting the levels of care requested by the resident/legal surrogate.During a concurrent interview and record review on [DATE] at 1:18 p.m., with Administrator (ADM), Resident 1's medical record, dated [DATE] was reviewed. The records indicated Resident 1 did not have an order for Code status (a patient's pre-determined medical decision regarding the type of resuscitation measures desired). The ADM stated, per facility policy, if a Resident does not have a code status on record, the Resident is considered a Full Code (a medical directive that indicates a patient's consent to receive all possible life-saving measures) until proven otherwise. The ADM states that Code status should be received and documented upon admission. The ADM further acknowledged that Resident 1 did not have an order for Code status in the record. ADM stated that the POLST, dated [DATE], indicated that Resident 1 was a Full Code and stated that we did not have their POLST in the chart till after the fact [after discharge] acknowledging that staff did not have a record of Resident 1's code status on admission. During a concurrent interview and record review on [DATE] at 1:18 p.m., with ADM, Resident's 3 medical record, dated [DATE], was reviewed. The Records indicated that Resident 3 did not have an order for Code status and no POLST or Advance directive was in their medical record. ADM confirmed that Resident 3 did not have an order for Code status, a POLST and/or Advance Directive were not in the record and acknowledged that per policy it should have been completed on admission.

Based on observation, interview and record review, the facility failed to ensure an opioid medication (pain medication that has a high risk of addiction) that was administered was documented on the appropriate record. This failure resulted in an inaccurate narcotic count and had the potential to result in diversion of a controlled medication. Findings: During a medication observation on 1/29/25 at 6 a.m. of Medication Cart 1, a narcotic blister pack (card with vacuum sealed medications) of Tramadol (opioid/pain medication that has a high risk for addiction and dependence [Schedule IV under the Controlled Substance Act]) 50 mg. was observed to contain 29 tablets. During a concurrent interview and record review on 1/29/25 at 6:05 a.m. with Licensed Nurse (LN 1), the Controlled Substances Declining Inventory Record or Narcotic Count Sheet/Log (Narcotic Log), dated 1/25/25 was reviewed. The Narcotic Log indicated, there were 30 tablets of Tramadol 50 in Medication Cart 1. Observation of Medication Cart 1 indicated, there were 29 tablets of Tramadol. LN 1 stated punched out the medication from the blister pack without signing the Narcotic Log causing the discepancy between the Narcotic Log count and how many Tramadol tablets were actually remaining in the blister pack. During a concurrent observation, interview and record review on 1/29/25 at 6:12 a.m. with the Director of Nursing (DON), the Narcotic Log was reviewed. The blister pack of Tramadol in Medication Cart 1 was observed and the DON confirmed there were only 29 tablets of Tramadol and the Narcotic Log indicated, 30 Tramadol tablets. The DON stated, The medication should have been signed out. During a review of the facility's policy and procedure (P&P), titled 5.4 Inventory Control of Controlled Substances, revisded 01/01/13, the P&P indicated in part, 1.2 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift . and 2. Facility should ensure that Facility staff count all Schedule III-V controlled substances in accordance with Facility policy and Applicable Law.

Based on record review and interview, the facility failed to follow it's policy and procedure to consistently monitor temperature controls from the time food leaves the kitchen to transport and distribution to residents. This failure occurred in 1 of 21 opportunities for monitoring. This failure risks residents receiving their food outside of appropriate temperature range. Findings: During a review of facility policy and procedure titled, Service Temperature of Food, dated 10/17/22, indicated in part .Record reading on Food Temperature Chart form 401, at beginning of tray line and at end of tray line . During a concurrent interview and record review on 12/01/22, starting at 2 p.m., with lead cook (LC), while reviewing the Temperature Log for breakfast, lunch and dinner for the week of 11/05/23 through 11/11/2023, log temperature recordings were missing for the dinner meal on 11/07/23. LC acknowledged missing temperature recordings, while also acknowledged that the responsibility for filling out log is the LC. LC confirmed she was the LC on 11/07/23, and stated, I think it slipped my mind, I know it's my responsibility, I just can't tell you why I didn't do it that evening.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had an accurate assessment recorded on their Minimum Data Set Assessment ((MDS) a tool for implementing standardized assessment and for planning care). For Resident 1, this failure had the potential to result in a plan of care (a communication tool for healthcare providers to ensure quality care is being provided) that did not match their actual needs. Findings: During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated, Resident 1 ' s functional status (ability to physically perform tasks) related to bathing was Total dependence [unable to participate in any of the bathing activity] . One-person physical assist [assisted by one staff person]. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated, Resident 1 ' s functional status related to bathing was Supervision - oversight help only . Two+ person physical assist [assisted by two or more staff persons]. During an interview on 08/16/2023 at 2:12 p.m. with Director of Nursing (DON), DON reviewed MDS dated [DATE] for bathing and stated Yea, that is wrong. DON reviewed MDS dated [DATE] and stated, that is correct. During a review of the facility ' s MDS manual titled, CMS ' s RAI Version 3.0 Manual, dated 10/2019, the MDS manual indicated, Bathing. How the resident takes a full body bath, shower or sponge bath, including transfers in and out of the tub or shower . Code for the maximum amount of assistance the resident received during the bathing episodes . supervision: if the resident required oversight help only . total dependence: if the resident is unable to participate in any of the bathing activity.

Based on interview and record review, the facility failed to accurately document the health condition related to medical condition for two of five sampled residents (Resident 9 and Resident 196), using the Minimum Data Set ((MDS - a tool used to assess and plan care of residents in a nursing facility) when: 1. For Resident 9 - had a missing diagnosis for anxiety. 2. For Resident 196 - had a missing diagnosis for depression. This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS). Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI), dated 10/2019, the P&P indicated, Medical record sources for physician diagnoses include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. 1. During a review of Resident 9's Face Sheet (FS), dated 4/23, the FS indicated, Resident 9 had a diagnosis of Unspecified Anxiety Disorder. During a review of the Physician's Order (PO), dated 4/19/23, the PO indicated, Resident 9 is to be given Lorazepam concentrates 2 milligrams/milliliter (mg/ml), 0.1 ml orally (by mouth) every six hours as needed for Anxiety manifested by restlessness and/or shortness of breath. During a review of the Physician Order and Informed Consent Verification Form (POICVF), dated 4/23, the POICVF indicated, the informed consent for the Lorazepam for diagnosis of Anxiety was obtained from Resident 9's responsible party. During a review of Resident 9's Care Plan (CP) - (a plan developed by the facility to identify resident's needs care and needs), dated 2/23, the CP indicated, Resident 9 uses anti-anxiety medication related to anxiety disorder. During a concurrent interview and record review, on 4/27/23, at 10:30 a.m., with the Director of Nursing (DON), Resident 9's most recent MDS section I, dated 2/17/23 was reviewed. The MDS indicated, a missing diagnosis for Anxiety. The DON stated, I already knew my deficiency. I missed the diagnosis for Anxiety. The DON further stated, I should have coded it. 2. During a review of Resident 196's PO, dated 4/10/23, the PO indicated, Resident 196 is to be given Trazodone 50 mg by mouth at bedtime for Depression resulting in insomnia . During a review of the POICVF, dated 4/10, the POICVF indicated, the informed consent for Trazodone for the diagnosis of Depression was obtained from Resident 196. During a review of Resident 196's CP, dated 2/23, the CP indicated, Resident 196 uses antidepressant medication related to diagnosis of Depression. During a concurrent interview and record review, on 4/27/23, at 10:30 a.m., with the DON, Resident 196's MDS section I, dated 4/17/23 was reviewed. The MDS indicated, a missing diagnosis for Depression. The DON acknowledged and stated, There was no documentation coding for Depression diagnosis in section I. The DON further stated, I missed documenting the diagnosis .It was my mistake. 39814

Based on interview and record review, the facility failed to ensure their facility policy and procedure titled, Elder Abuse Prevention, Identification, Investigation, and Reporting, was implemented when a facility staff member failed to report an allegation of abuse in accordance with the facility policy and procedure on abuse. A Certified Nursing Assistance (CNA1) did not reported alleged abuse of Resident 1 to the facility Administrator (ADM) immediately as per the facility's policy and procedure. This facility failure has the potential for Resident 1 and other residents of the facility to be unprotected if the facility did not conduct an immediate investigation of abuse and prevent it from reoccurring. Finding: Review of the facility policy and procedure titled Elder Abuse Prevention,, Identification, Investigation, and Reporting, dated 03/21/21, indicates in Section III: If an employee has reason to believe that any form of abuse has or will occur, they shall immediately report following reporting procedures as indicated in this policy and the Elder Justice Act Policy . During an interview on 08/20/2021, at 10:00 a.m., CNA 1 revealed she witnessed CNA 2 striking a resident across the mouth. CNA 1 indicated she came forward to report this allegation to the Director of Nursing (DON) 2-3 weeks later. CNA 1 further explained she knew she was to report this allegation immediately as she has had training before about reporting requirement. CNA 1 acknowledged she did not follow the facility policy and procedure. During an interview on 09/03/2021, at 1:50 p.m., the DON and ADM confirmed they became aware of the allegation on 7/22/2021, 2-3 weeks after the alleged incident. The DON and the ADM explained, the timeframe for reporting this type of allegation is immediately. The DON indicated the charge nurse should have been notified prior to the end of the shift. The charge nurse would then be expected to notified the DON and ADM. Both the DON and the ADM acknowledged CNA 1 did not report her allegations immediately as per the facility policy and procedure, but should have.

Based on Observation, interview, and record review the facility failed to implement their policy and procedure on Abuse when they did not fully investigate an allegation of abuse for one of three sampled Residents (Resident 2) and when they did not suspend immediately two employees who had been accused of potential abuse. This failure allowed CNA1 to continue caring for residents from 11/5/2020 until 1/15/2021 without any investigation into the allegations made by Resident 2 and led to a second allegation against CNA 1 of , being rough during care by another Resident, (Resident 1). CNA1 was not sent home or removed from direct care of other residents during either of the two shifts in question, after the allegations were made by both Resident 1 and Resident 2 allowing CNA1 potential access to both Resident 1 and Resident 2 immediately following allegations of abuse and mistreatment. CNA 2 was not removed from care immediately following an allegation of potential abuse allowed CNA2 potential access to Resident 1 and other residents in the facility. Findings: A review of the facilities policy and procedure titled, Elder Abuse Prevention, Identification Investigation & Reporting, dated 6/22/2018, indicated in part, Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the person in charge of the Community, of all reports, allegations or suspicions of potential abuse, neglect or misappropriation of property. Upon learning of the report, the Administrator or in the absence of the Administrator, the person in charge shall initiate the investigation . Under , VI Protection the, Community Staff shall arrange to protect residents from harm during an investigation. This shall include suspension, if appropriate, of an alleged offender, or other means to temporarily protect a resident during an investigation .Employees - The individual(s) accused will be immediately suspended until the results Response of the investigation have been reviewed by the Administrator or designee . Under the section titled, VII. Staff Reporting/Response, under number 2. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. A review of the employee files for two Certified Nursing Assistants (CNA1 and CNA2) involved in the Facility Reported Incident was conducted on 1/28/2021 with the Administrator (Adm) and the Director of Nursing (DON) present. During the review of CNA1's employee file an allegation of abuse was discovered with a date of 11/5/2021. In the letter from the Director of Staff Development (DSS) , dated, November 05, 2020, Resident 2 made allegations against CNA1 which included, At night she (CNA1) comes at me like a witch. Resident 2 also indicated that she did not want CNA1 taking care of her anymore. In the bottom of the letter it indicates that the DSS reassured Resident 2 that she would not have CNA1 care for her anymore. The letter documents the following, I assured (Name of Resident 2) that the DON and I (DSS) would speak together and handle the situation. I also told her (Resident 2) that she would not have (name of CNA1) again. (Name of CNA1) was pulled from the assignment and given another resident. A review of Resident 1's Face sheet indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. A Review of Resident 1's minimum data set (MDS - comprehensive resident assessment) assessment dated [DATE] indicated, Resident 1's BIMS score was 14. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well a resident is functioning cognitively (mental awareness). BIMS scores 13 to 15 means intact cognition. 8 to 12 means moderately impaired cognition. 0-7 means: severely impaired cognition. In an interview with Resident 1, on 1/28/2021 at 12:09 pm, Resident 1 indicated that CNA1 and CNA2 were trying to change her and that they were unaware of her pelvic fracture. Resident 1 further indicated that despite her screaming out in pain CNA1 and CNA2 continued to pull on her legs roughly. Resident 1 indicated she had to call the nurse to come in her room and that she also called her daughter and her daughter was on the phone with her when the nurse was in the room. The nurse notified the DON and the RN supervisor and CNA1 was removed from Resident 1's care for the rest of the shift but CNA1 was still allowed to care for other residents within the facility despite the allegations of alleged abuse and rough handling from 1:40 am until change of shift at 7 am. This allowed CNA1 potential access to Resident 1 during the rest of the shift. In an interview with the ADM and the DON on 1/28/2021 at 1:20 p.m., both acknowledged they had not conducted an investigation of the allegations made on 11/5/2020 by Resident 2, and they acknowledged CNA1 was allowed to continue working between 11/5/2020 and 1/15/2021 and was also allowed to finish her shift on 1/15/2021. They acknowledged CNA2 was also allowed to finish her shift on 1/15/2021 which also allowed CNA2 potential access to Resident 1 and other residents in the facility.

Based on record review and interview, the facility failed to initiate a care plan (a plan that provides direction for individualized care of a resident) for one of three sampled residents (Resident 2) when Resident 2 made an allegation of abuse. This failure had the potential for a lack of continuity of care for Resident 2 during a time of crisis. Findings: During a review of the facility's policy and procedure (P&P) titled, Elder Abuse Prevention, Identification, Investigation, and Reporting, dated 10/30/15, the P&P indicated during the investigation of a report of abuse The Community nursing staff conduct post-allegation, 72 hour monitoring and documentation. During a review of the facility's policy and procedure (P&P) titled, Change of Condition Guidelines, dated 8/19/19, the P&P indicated a change of condition includes, .a significant change in the resident's physical/emotional/mental condition. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 9/2013, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (relating to the interrelation of social factors and individual thought and behavior) and functional needs is developed and implemented for each resident .the interdisciplinary team must review and update the care plan: when there has been a significant change in the resident's condition. During a concurrent interview and record review, on 3/3/20, at 1:50 p.m., with the director of nursing (DON), the DON was unable to find a care plan specific to Resident 2's allegation of abuse. The DON stated, An abuse allegation is a significant change. A care plan is a communication form. I do believe the care plan should be done. The DON was unable to find social services notes documenting 72 hour monitoring of the psychosocial well-being of Resident 2 after the allegation of abuse was made.

Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when: 1. Two vials of expired [MEDICATION NAME] (a blood thinning medication) were found in a facility emergency medication kit (E-Kit) (a kit that stores a variety of medications intended for emergency resident use). 2. Expired supplies were found in the intravenous (IV) supply cart. These failures had the potential for residents to receive medications which may be ineffective or altered, and for residents to to have potential complications from use. Findings: 1. During an observation and concurrent interview with a licensed nurse (LN1), on [DATE], at 10:20 a.m., two expired vials of [MEDICATION NAME] were found in a facility E-Kit with a labeled expiration date of [DATE]. LN1 confirmed the two vials of [MEDICATION NAME] were expired and acknowledged she would contact pharmacy to get them replaced. 2. During an observation on [DATE], at 10:40 a.m., in the IV supply cart the following items were found: a. Four expired [MEDICATION NAME]-iodine prep pads (an antiseptic used to clean the skin to prevent infection) were found. Three [MEDICATION NAME]-iodine prep pads were labeled with an expiration date of ,[DATE] and one [MEDICATION NAME]-iodine prep pad was labeled with an expiration date of ,[DATE]. b. One expired [MEDICATION NAME] applicator (an antiseptic used to clean the skin to prevent infection) was labeled with an expiration date of ,[DATE]. c. Six expired [MEDICATION NAME] swab sticks were expired. Four [MEDICATION NAME] swab sticks were labeled with an expiration date of ,[DATE]. Two [MEDICATION NAME] swab sticks were labeled with an expiration date of ,[DATE]. d. One expired alcohol swab stick (an antiseptic used to clean the skin to prevent infection) was found with an expiration date of ,[DATE]. During an interview on [DATE], at 10:56 a.m., LN1 confirmed the supplies were expired and stated We will dispose of these. The facility policy and procedure titled, Disposal/Destruction of Expired or Discontinued Medication, dated ,[DATE], indicated in part, Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 37) had a splint applied to the left hand as ordered by the medical doctor (MD). This facility failure had the potential for Resident 37 to suffer complications, such as worsened contracture (a permanent shortening of muscle, tendon, or scar tissue) producing deformity or distortion. Findings: According to Potter and Perry's, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice, Nurses are obligated to follow physician order [REDACTED]. During an observation on 10/21/19, at 4:14 p.m., Resident 37's left hand was noted to be clenched into a fist, and no splint was in place. Resident 37's Responsible Party (RP) manually opened Resident 37's fingers and stated Resident 37's splint is supposed to be on. During a review of the clinical record for Resident 37, the Order Listing Report, dated 4/12/19, indicated in part, Splint wearing schedule: beige splint for left hand, on 2 hours/off 2 hours during waking time i.e. after breakfast on approx 9:30-12:30, off for lunch, on in p.m approx. 2:00-5:00, off during dinner . During a review of Resident's 37's, Treatment Administration Record (TAR), dated (MONTH) 2019, did not contain splint application and removal documentation. A review of Resident's 37's, Care Plan Report, dated 7/26/19, indicated a focus is, Resident at risk for skin breakdown to left palm related to neurological dysfunction to left hand causing left hand contracture. One intervention states, Splint wearing schedule: beige splint for left hand, on 2 hours/off 2 hours during waking time i.e. after breakfast on approx 9:30-12:30, off for lunch, on in pm approx. 2:00-5:00 off during dinner . During an interview with the Administrator (ADM), and the Director of Nursing (DON), on 10/21/19, at 5:16 p.m., the DON stated there is no mechanism for documentation of the splint being applied or removed, and acknowledged that the splint was not in place as it should have been. The facility policy and procedure titled, Resident Mobility and Range of Motion, dated 1/1/19, indicated in part, Interventions may include therapies, the provision of necessary equipment, and/or exercises and is based on professional standards of practice .

Based on observation, interview and record review, the facility failed to maintain equipment in a safe and sanitary manner for one of 12 sampled residents (Resident 12). This facility failure had the potential for Resident 12 to develop an infection from a surface that could not be adequately sanitized. Findings: During an observation and concurrent interview with the Director of Staff Development (DSD), on 10/22/19, at 3:54 p.m., a two inch tear was noted in the vinyl on the left arm rest of a reclining geriatric chair (large, padded, comfortable chair with casters designed to allow patients to sit comfortably while being fully supported) occupied by Resident 12. The DSD acknowledged that the chair cannot be adequately sanitized, and should not be in use. The facility policy and procedure titled, Community - Care Equipment, dated 9/21/17, indicated in part, It is the policy of (facility name) to maintain resident care equipment in a sanitary manner, both in appearance and also in terms of reduction of infectious potential.

Based on observation, interview and record review, the facility failed to follow the planned therapeutic menu for the heart healthy diet for one of 12 sampled residents (Resident 29). This facility failure has the potential to increase complications of [MEDICAL CONDITION] for Resident 29. Findings: On 10/15/18 at 01:04 PM, during a dining observation, Resident 29's dietary tray card was reviewed. Resident 29's dietary card included Regular Diet; Heart Healthy; Small Portion .10) Milk - 4 oz (ounce) . Resident 29 was observed with cranberry juice, and milk was not observed served to Resident 29. On 10/15/18 at 01:19 PM, a server (Server 1) stated Resident 29 had not wanted milk, she only wanted cranberry juice. Server 1 was asked what type of milk would have been served to Resident 29 if she had wanted milk. Server 1 looked at Resident 29's dietary tray card, and stated, Milk- 4 oz would be whole milk unless otherwise specified at the top to give 2% low fat milk. Server 1 clarified on the top of the dietary tray card under a section that included allergies [REDACTED]. Server 1 stated she was employed in her position for about a year and half. On 10/16/18 at 1:19 P.M., during a joint dining observation, a server (Server 2) observed Resident 29 drinking milk. Server 2 was asked what kind of milk Resident 29 was drinking. Server 2 reviewed Resident 29's dietary tray card, and stated, She was served whole milk because milk was listed on her tray ticket. Server 2 stated that if it were something different than whole milk like low fat milk it would have been listed at the top of the meal tray ticket and pointed to the allergies [REDACTED]. On 10/16/18 at 3:19 PM, during a joint interview with the Interim Food Service Director (IFSD) and a Registered Dietitian (RD 1), both stated that per the planned therapeutic heart healthy diet that 4 oz. skim (fat free) milk should have been served. The IFSD stated that preferences could be listed at the top of the dietary tray ticket. The IFSD stated he expected the servers to go into the kitchen and look at the therapeutic diet spreadsheet in order to know the planned beverage to be served for therapeutic diets. A copy of Resident's 29 dietary tray card was provided by the IFSD after completion of the dining observation later on that day. A review of Resident 29's dietary tray card included, Regular Diet; Heart Healthy; Small Portion ., allergies [REDACTED]. A review of the planned therapeutic heart healthy diet menu approved by a registered dietitian indicated, Heart Healthy . 4 oz. skim milk . Further review of the planned menus indicated a small portion of milk would be 4 oz of skim milk. The planned menu indicated a Large Portion would be 8 oz of milk. A review of Resident 29's physician ordered diet, dated 6/14/18, indicated Heart Healthy (sodium/fat/cholesterol restriction) diet, regular texture, regular/thin fluid consistency, small portions for diet. The facility's policy and procedure titled Cycle Menus revised 9/14/18, indicated Procedure .3. Menus must be followed as written . The facility's policy and procedure titled Dietary Tray Card revised 9/4/18, indicated 1. The tray card should contain the following information on each resident: .e. Resident's diet pattern, if different from the diet manual or therapeutic diet extension sheet .

Based on observation, interview and record review, the facility failed to ensure food was stored in a safe and sanitary manner when: 1. Health shakes (nourishment to increase calories and protein) were not dated to ensure they would be used within fourteen days once thawed in accordance with manufacturer's guidelines. 2. A serving utensil was stored inside a bin of sugar, and a dented can of soup was available for use for the residents which had the potential to cause cross-contamination and/or infection. As a result, the resident's were placed at increased risk of infection and/or diminished food quality. Findings: 1. On [DATE] at 09:14 AM., inside the walk-in refrigerator, was a bin that contained individualized sized health shakes. The bin was labeled with a date of [DATE] - [DATE]. The Interim Food Service Director (IFSD) stated the facility received the health shakes frozen and then immediately were placed in the refrigerator. The IFSD stated the dates of [DATE] - [DATE] meant the facility received the shakes on [DATE] from the vendor and placed them in the refrigerator on that day. The IFSD stated the use by date was [DATE]. The IFSD was asked to read the manufacturer's guidelines that were located on each of the individualized sized 4 ounce cartons of the health shakes which indicated to use within fourteen days once thawed. During a concurrent interview, the IFSD acknowledged their current dating system for the refrigerated health shakes were not in accordance with the manufacturer's guidelines. The facility's policy and procedure titled Labeling and Dating For Safe Storage of Food revised: [DATE], indicated .labeling and dating are critical in order to promote food safety ., Follow manufacturer guidelines where different than storage guide . 2. On [DATE] at 09:42 AM, an observation was conducted of a kitchenette located in the dining room. A lead server (LS) observed a utensil stored inside of a container that had brown sugar. The LS stated that the above observation was acceptable storage practices. Concurrently, there were three cans of unopened tomato soup in which one can was observed with a dent along the rim. The LS was asked if the canned soups were acceptable to serve to residents. The LS picked up each can of soup and checked to ensure the date was not expired, and stated that they could be served to residents. On [DATE] at 09:48 AM, the Interim Food Service Director (IFSD) observed the spoon in the bin of brown sugar and stated the spoon could not be stored that way due to infection control. On [DATE] at 09:49 AM, the IFSD observed the dented can of tomato soup and stated that dented cans of food were not acceptable to use for resident consumption. Concurrently, the IFSD stated he routinely checked food storage inside of the kitchen but rarely in the kitchenette. The facility's policy and procedure titled Food Storage revised: [DATE], indicated .Food items should be stored, thawed, and prepared in accordance with good sanitary practice, .Dented or bulging cans should be placed on Damaged Goods Shelf and returned for credit, .Label and date all storage containers or bins. Keep free of scoops .

Based on observation, interview, and record review the facility failed to: 1. Maintain an eyewash station in clean and sanitary condition. This facility failure had the potential to cause infection and serious visual injury. 2. Ensure staff performed hand hygiene while assisting two different residents to eat lunch in the dinning room. This facility failure had the potential to result in cross-contamination between two residents (Resident 16 and 17). Findings: 1. According to occupational safety and health administration (OSHA), (MONTH) 21, (YEAR) health care facilities' eye wash stations must be plumbed and maintained in clean and working order. During an observation and concurrent interview in the med room on 10/17/18 at 10:50 AM the designated emergency eyewash station had dirt, debree, and white substances visible in the basin and on the faucet . The director of nursing (DON) agreed the eyewash station was not in safe or clean condition. 2. Record review of the facility lesson plan titled Feeding Challenges dated 10/17/18, indicated assist one resident at a time, no cross feeding. Hand hygiene before moving on to another resident. During an observation on 10/15/18, at 1:15 PM, in the dining room, a certified nursing assistant (CNA 1) was feeding two residents (Resident 16 and 17) with the same hand without performing hand hygiene. Resident 17 spit food in the napkin that CNA 1 was using to wipe resident 17's mouth, CNA 1 did not perform hand hygiene prior to assisting Resident 16 with eating. During an interview on 10/15/18, at 1:41 PM., the director of nursing (DON) indicated, CNAs should not be feeding two residents with the same hand without performing hand hygiene.

Based on record review and interview, the facility failed to follow the policy and procedure of reporting significant weight changes to the physician within 24 hours for one of 11 sampled residents (Resident 3). This failure had the potential to result in nutritional needs or changes of condition not being met and evaluated in a timely manner. Findings: During a review of Resident 3's weight and vital summary for 2017, Resident 3 had a documented weight loss of 6.4 pounds in a month on 4/4/17. Resident 3 had documented weight gains of 16.6 pounds on 5/2/17, 10.2 pounds on 6/6/17, and 5.2 pounds on 7/5/17. The nurses progress notes had no documentation of notification of the physician for the weight changes. A review of the facility policy and procedure titled Resident Weights, Lengths, and Vital Signs undated, indicated in part, .significant change in weight requires an initial nursing assessment to determine the cause of the significant weight variance and to provide an assessment of the resident's condition to the attending physician when the weight change is reported (within 24 hours). A review of the facility policy and procedure titled Licensed Nurses Assessments and Notes dated 7/2017, indicated in part, Physician shall be notified promptly of a change in weight of five pounds within one month unless otherwise indicated by the physician. During an interview with the director of nurses (DON), on 10/17/17, at 4:45 p.m., the DON reviewed the clinical record and confirmed there was no documentation to show the physician was notified of the weight changes.

Based on record review and interview, the facility failed to follow their fall precaution policy and consistently implement interventions to prevent injury related to falls for one of three sampled residents (Resident 1). As a result, Resident 1 suffered from multiple falls; the last fall resulted in a traumatic brain injury (subdural hematoma -swelling and bleeding of the brain). Findings: During a review of the clinical record for Resident 1, the face sheet dated 1/20/16, revealed [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE], also revealed Resident 1's cognition (mental awareness) was intact, required extensive assistance for bed mobility, transfers and ambulation, with occassional incontinence of urine. Review of the fall risk assessment dated [DATE], 3/01/16, and 4/18/16 indicated, Resident 1 was identified as a high risk for falls due to history of falls, balance problem, inability to ambulate, incontinence, and use of medications. Review of the nurses notes dated 1/12/16 to 5/6/16, indicated, Resident 1 was alert with forgetfulness and confusion. The nurses notes also indicated the resident fell on [DATE], 3/1/16 and 5/6/16. On 5/6/16, Resident 1 was transfered to hospital and identified to have a brain bleed as a result of the fall. During a concurrent record review and interview on 6/2/16 beginning at 11:45 a.m., the Director of Nurses (DON) indicated the investigation surrounding Resident 1's falls revealed the January fall was from the bed to the floor where the resident was found. After the January fall, the fall precaution interventions were changed to include a tab alarm (safety device), continued use of keeping the call light within easy access, and bed in the lowest possible position. The nurse's notes dated 1/14/16 at 4:50 p.m., revealed, The daughter (responsible party for Resident 1) was called and it was discussed regarding the application of a tab alarm for safety. The tab alarm was applied with the permission of Resident 1's responsible party. On 3/1/16, Resident 1 fell from the bed to the floor again. No revisions or updates were noted on the careplan. The facility was unable to identify or produce evidence to indicate the tab alarm was in use. On 5/6/16, Resident 1 fell again sustaining a head injury and was transported to the hospital. Review of the interdisciplinary notes (IDT) dated 1/19/16 and 4/14/16 indicated, no discussion occurred regarding Resident 1's January and March falls nor exploration of other alternative fall prevention measures. During an interview on 5/11/16 at 8:45 a.m., the facility administrator explained on 5/6/16 sometime in the afternoon, Resident 1 was first heard calling out for help from Resident 1's room and was found on the floor by a certified nursing assistant (CNA) beside the bed. During an interview on 5/11/16 at 9:17 a.m., the DON explained, there were no floor pads near or under the bed, no bed or personal tab alarm or sensing devices in place during the 5/6/16 fall and could not explain why floor mats had not been explored as a precautionary measure for injuries related to falls for Resident 1. Review of the clinical record revealed, Resident 1 was admitted to the intensive care unit (ICU) on 5/6/16 after sustaining a traumatic brain injury related to the fall. During an interview on 6/2/16 at 11:45 a.m., the DON explained the facility investigation of the fall incidents for 3/1/16, and 5/6/16, revealed no presence of any alarm when Resident 1 fell . The DON was not able to locate any documentation as to any conversation with Resident 1's responsible party as to any refusals of the use of a tab alarm after it was implemented on 1/14/16. Review of the facility's policy and procedure titled, Fall Intervention Policy and Procedure, dated 11/1/15, indicated, The policy is to ensure a safe environment . The steps necessary, following a fall, are to review and update causative factors related to the fall; nursing staff will determine interventions necessary, and initiate or update plan of care to prevent reoccurrence of a fall or to minimize injury. During an interview on 6/16/16, at 10:45 a.m., the DON and Director of Staff Development (DSD) confirmed the facility did not follow the fall policy in Resident 1's fall incidents.